Provider Demographics
NPI:1548990476
Name:SHINE, ELLIOT ABRAHAM (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:ABRAHAM
Last Name:SHINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MARTIN CT
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1620
Mailing Address - Country:US
Mailing Address - Phone:516-695-0103
Mailing Address - Fax:
Practice Address - Street 1:25 S OYSTER BAY RD
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-5002
Practice Address - Country:US
Practice Address - Phone:516-365-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI029984001223P0221X
FL272871223P0221X
NY0640601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-3971298OtherEMPLOYEE IDENTIFICATION NUMBER